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Feature
How Immunotherapy is Transforming
Cancer Treatment Options for Patients
By Justin Favaro, MD, PhD, Oncology Specialists of Charlotte, PA Before and After Immunotherapy
A52-year-old female patient with
I mmunotherapy is by no means new to the world of cancer stage IV high-grade neuroendocrine
treatment. In fact, it was first discovered in 1891 by William tumor of the pancreas, metastases
B. Coley, MD, who injected killed bacteria into tumors and to the liver and peripancreatic lymph
realized a reduction in the tumor size. Fast forward to 2019, and nodes.
multiple immunotherapy options are now available for patients. Fig.1:PET scan before starting
immunotherapy.Note:High volume
Immunotherapy, according to the American Cancer Society, disease in liver and lymph nodes.
is a specialized treatment that uses a person’s immune system to
attack cancer cells. As seen in Fig. 1, tumor cells can turn off T Fig.2:After three treatments of
cell activity by interacting through specific receptors. This allows immunotherapy, almost complete
tumor cells to evade the immune system and continue to grow. resolution of cancer.
Drugs which block the T cell-tumor interaction, such as Keytruda
as seen in Fig. 3, allow the T cells to remain active and form an melanoma with metastases to the brain and liver. He was treated
immune response against the tumor cells. with immunotherapy and radiation therapy and has since led an
active life. What a dramatic improvement in outcomes for this
In 2017, I began treating a 52-year-old otherwise healthy disease compared to just a few years ago.
female with stage IV high-grade neuroendocrine tumor of
the pancreas. She presented with metastases to the liver, Immunotherapy does not work for all patients. Tumors with
peripancreatic lymph nodes and abdominal pain. I treated her the highest mutation burden (lung, melanoma and bladder) have
with combination chemotherapy, and she had improvement shown the best response rates, while colon, prostate and others
of her abdominal pain but suffered the inevitable side effects have a lower response rate. The amount of expression of PD-L1
of the treatment. After one year on different combinations of receptor on the tumor surface can predict the benefit of these
chemotherapy, her disease progressed with increasing pain and drugs in some cases. The side effects typically are manageable
increasing size of the liver and peripancreatic metastases. We with steroids, but rarely they can be more severe or fatal.
began treatment with dual-agent immunotherapy, and after three
treatments, she had a dramatic clinical benefit and reduction We are seeing more immunotherapies studied earlier in the
in the size of the metastases (see Fig. 2). The patient had side course of the disease and combined with chemotherapy or targeted
effects of diarrhea and pneumonitis, which were controlled with agents. With success seen in many highly mutated tumors, I am
steroids. Recently, she suffered a stroke and is currently off hopeful for continued improvements in outcomes for patients with
treatment, recovering well and remains in remission. the less immunogenic tumors. The use of newer immunotherapy
drugs alone, or in combination with other treatments, may
Many of us followed the story of former President Jimmy eventually transform cancer into a chronic disease.
Carter, who in 2016, at the age of 91, was diagnosed with stage IV
Fig. 3:
Image courtesy of Merck - Keytruda Mechanism of Action (keytruda.com)
8 | July/August 2019 • Mecklenburg Medicine
